Provider Demographics
NPI:1104511807
Name:HICKS, JENNIFER LYNNE (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:HICKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 SHOSHONE DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-9127
Mailing Address - Country:US
Mailing Address - Phone:614-579-2543
Mailing Address - Fax:
Practice Address - Street 1:4461 STATE ROUTE 159 STE A
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-6000
Practice Address - Country:US
Practice Address - Phone:740-779-4900
Practice Address - Fax:740-779-4909
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.033661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine